Healthcare Provider Details

I. General information

NPI: 1265040711
Provider Name (Legal Business Name): DIVERSITY HOME HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2455 S HOWELL AVE
MILWAUKEE WI
53207-1638
US

IV. Provider business mailing address

2455 S HOWELL AVE
MILWAUKEE WI
53207-1638
US

V. Phone/Fax

Practice location:
  • Phone: 414-810-4675
  • Fax: 414-885-0877
Mailing address:
  • Phone: 414-810-4675
  • Fax: 414-885-0877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. EVARISTO ANTONIO RODRIGUEZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 414-422-5317